J Hepatobiliary Pancreat Sci (2014) 21:E41–E47 DOI: 10.1002/jhbp.95
TECHNICAL VIEW
Tips on laparoscopic distal pancreatectomy Nobutsugu Abe · Toshiyuki Mori · Masanori Sugiyama
Published online: 18 February 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract An increasing number of laparoscopic pancreatic procedures are currently carried out worldwide. Laparoscopic distal pancreatectomy (LDP) appears to be technically and oncologically promising in selected patients with benign tumors and low-grade malignancies of the pancreatic body/tail, and is now widely adopted. Here, we described our standard procedures of LDP and some tips on LDP. Recent important insights into some variations/ options of LDP including spleen preservation, hand-assisted procedure, and single-incision surgery are also reviewed in this article.
Keywords Laparoscopic distal pancreatectomy · Laparoscopic surgery
Introduction Although laparoscopic pancreatic surgery represents the most advanced application of surgical laparoscopy [1], an increasing number of laparoscopic pancreatic procedures are currently carried out worldwide [2]. Among them, laparoscopic distal pancreatectomy (LDP) is now performed more frequently in the surgical treatment of benign diseases and low-grade malignancies in the pancreatic body and tail [3, 4]. There has been no prospective randomized controlled trial comparing LDP with open distal pancreatectomy; however, recent systematic reviews have shown that LDP is a safe, feasible, and effective surgery for patients with such lesions in terms of both surgical and oncologic outcomes [3, 4]. The issue of spleen preservation in LDP has been heatedly debated and has been controversial in relation to the indications of pancreatic resections and technical problems [5–7]. Here, we focus on the technical aspects of LDP and
N. Abe (*) · T. Mori · M. Sugiyama Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan e-mail: [email protected]
describe our techniques of laparoscopic “classic” distal pancreatectomy (LDP with splenectomy). We further comment on several options/variations of LDP including spleen preservation, hand-assisted procedure, and singleincision surgery.
Operative procedures and techniques (LDP with splenectomy) Patient position and setup The patient is placed in supine position on a split-leg operating room table. The surgeon stands on the left side, the assistant on the right side, and the scope operator between the legs of the patient. Initial entry into the peritoneal cavity is made at the umbilicus by the Hasson open technique. A 12-mm trocar is introduced into the peritoneal cavity, and a pneumoperitoneum is generated using carbon dioxide at a pressure of 8–10 mmHg using a laparoscopic insufflator. A 10-mm 30-degree laparoscope is used to visualize not only the operating field but also the liver and all peritoneal surfaces through the transumbilical port. Four additional trocars (each 5–12 mm) are inserted into the left upper, left lower, right upper, and right lower quadrants under laparoscopic supervision (Fig. 1a). We use laparoscopic coagulating shears (LCS) and/or a vessel sealing system (VSS) for all the resection procedures. Retraction of the liver is sometimes necessary to ensure an adequate working space of the diaphragmatic hiatus and upper spleen, which is usually concealed under the lateral segment of the liver. Retraction of this segment is paramount for nonstressful access to this region. Such retraction can easily be achieved by simple grasping of the parietal peritoneum anterior to the hiatus with a Mini Loop Retractor II (Covidien, Mansfield, MA, USA) traversing underneath the lateral segment of the liver (Fig. 1b). To avoid compression-related injury and parenchymal fractures of the liver caused by the Mini Loop Retractor II, we place a polyurethane sponge (Securea, Hogy Medical Co., Tokyo,
E42 Fig. 1 Setup of laparoscopic distal pancreatectomy. (a) Positions of five trocars. (b) Retraction of liver. Arrowhead, Mini Loop Retractor II (Covidien, Mansfield, MA, USA); arrow, polyurethane sponge (Secrea)
Fig. 2 Wide opening of gastrocolic omentum. (a) Division of gastrocolic omentum. (b) Exposure of anterior wall of superior mesenteric vein at inferior border of pancreas. (c) Dissection of gastrosplenic ligament including short gastric vessels. Clips (arrows) should be available in case there is bleeding that needs to be controlled. (d) Dissection of phrenosplenic ligament (arrow) above superior pole of the spleen
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47
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Japan) between the liver and the Mini Loop Retractor II (Fig. 1b). Division of gastrocolic omentum The first phase of the operation is the formation of a wide opening of the gastrocolic omentum for good visualization of the anterior pancreas. Entry into the lesser sac is achieved by dividing the left side of the gastrocolic omentum. The assistant lifts up the greater curvature of the stomach using the dual grasping forceps and expands it with the forceps in both hands. This procedure gives a good field of view (Fig. 2a). Leave the gastroepiploic vessels on the stomach side of the dissection. Dissect the right side of the gastrocolic omentum from the transverse colon and anterior sheet of the transverse mesocolon. In this procedure, the end point of this dissection is confirmed upon reaching Henle’s trunk area and the superior mesenteric vein at the level of the inferior border of the pancreas. At this point, we usually
expose the anterior wall of the superior mesenteric vein at the inferior border of the pancreas (Fig. 2b). The assistant changes sides to stand on the left of the patient and pushes the gastric wall toward the right side with the right-hand grasper to put strain on the gastroepiploic arcade. Dissect the left side of the gastrocolic omentum towards the lower pole of the spleen. The resection line of the gastrocolic omentum should be confirmed from the front and back to avoid transverse colon and mesocolon injury. The dissection is then continued up to the gastrosplenic ligament including the short gastric vessels. This procedure allows complete exposure of the anterior pancreas and splenic hilum. The dissection of the gastrosplenic ligament can often be completed using the LCS or VSS; however, clips should be available in case there is bleeding that needs to be controlled (Fig. 2c). After forming this wide opening of the gastrocolic omentum, the stomach can be retracted upward to expose the anterior pancreas and the remaining attachments between the posterior stomach and the anterior
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47 Fig. 3 Laparoscopic ultrasonography. (a) An ultrasonography image can be split with the video to allow for a picture-in-picture view. Arrow, laparoscopic ultrasound probe. (b) After assessment of the tumor and anatomical structures, the pancreatic transection line (arrows) is planned
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pancreas. At this point, it is preferable to dissect the phrenosplenic ligament above the superior pole of the spleen (Fig. 2d). Laparoscopic ultrasonography (Video S1) A laparoscopic ultrasound probe is inserted and applied anteriorly to the pancreas. It is useful that the ultrasonography image is split with the video to allow for a “picture-in-picture” view (Fig. 3a). Assess the tumor and plan the pancreatic transection line by laparoscopic ultrasonography (Figs 3a,b). This allows assessment of the relationship between the tumor and the splenic vessels. Laparoscopic ultrasonography plays a pivotal role in deciding whether to perform spleen preservation or not. Mobilization of the pancreas (Video S1) The next phase of the operation is mobilization of the pancreas. Divide the posterior peritoneum at the inferior border of the pancreas near the superior mesenteric vein that is exposed in the first phase of the operation (or near the planned transection line of the pancreas). Divide the retroperitoneum/pancreatic line; this plane is mostly avascular. Identify the inferior mesenteric vein as it approaches the splenic vein and avoid it. Mobilize and lift the pancreas forward from this plane to expose the splenic vein lying posterior to the pancreas (Fig. 4a). Continue to divide the peritoneum laterally toward the pancreatic tail and divide the splenocolic ligament to expose the inferior pole of the spleen (Fig. 4b). Dissection in this area must be carried out with extreme care, because hemorrhage from the splenic vessels could easily occur. It is not absolutely necessary to mobilize the spleen at this point. During this pancreatic mobilization, it is preferable to identify the splenic artery inferiorly of the pancreas (Fig. 4c).
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Next, opening the peritoneum along the superior border of the pancreas will reveal the common hepatic artery and splenic artery. The superior edge of the pancreas is carefully excluded downwards by the assistant using the lower grasping forceps, which provides a good view. Care should be taken to elevate the peritoneum with a grasping forceps prior to its incision so as to prevent injury to the small vessels. The splenic artery is then encircled with a cloth tape near its root using a right-angle forceps and completely isolated from the pancreas. If the pancreatic transection is performed above the portal vein, it is preferable that the common hepatic artery is completely separated from the pancreas. Around the planned pancreatic transection line, we usually encircle and tug the pancreas using a 5-mm-wide cloth tape to form a wide “window” below the pancreas (separation of the pancreatic neck from the superior mesenteric vein/portal vein) (Figs 4d,e). Before this procedure, dissection between the pancreas and the superior mesenteric vein/portal vein proceeding upward is necessary (Figs 4d,e). Before the pancreatic transection, assessment of the pancreatic transection line by the laparoscopic ultrasound should be done once again. The splenic vessels may be divided simultaneously during pancreatic transection using an endoscopic linear stapler. However, we prefer that pancreatic transection is carried out after dividing the splenic vessels to obtain a secure clump of these vessels. The splenic artery is first divided using clips and VSS followed by the splenic vein in the same manner at the line of the planned pancreatic transection. However, when the pancreas is transected on the right side of the SMA, it is occasionally difficult to expose the splenic vessels before transection of the pancreas. Under such situations, the splenic vessels can be divided simultaneously during pancreatic transection using the endoscopic linear stapler.
Division of the splenic vessels (Video S2)
Transection of the pancreas (Video S3)
After the pancreatic mobilization, we usually isolate the splenic vein from the posterior wall of the pancreas near the planned line of pancreatic transection.
After dividing the vessels, the pancreas is transected using an endoscopic linear stapler. To insert this stapler (over 12 mm in thickness) into the peritoneal cavity, we enlarge
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Fig. 4 Mobilization of pancreas. (a) Mobilization of pancreas from avascular plane to expose splenic vein lying posterior to pancreas. (b) Division of splenocolic ligament (arrow) to expose inferior pole of spleen. (c) Identification of splenic artery located inferiorly of pancreas. *, polyurethane sponge (Secrea). (d) Dissection between the pancreas and the superior mesenteric vein/portal vein proceeds upward. SMV, superior mesenteric vein; IMV, inferior mesenteric vein. (e) Complete separation of pancreas from superior mesenteric vein/portal vein, splenic artery, and common hepatic artery. CHA, common hepatic artery; PV, portal vein; SA, splenic artery; SV, splenic vein
Fig. 5 Transection of pancreas. (a) An endoscopic linear stapler is delivered through the surgical glove fixed in a ring protector placed in an enlarged umbilical incision. (b) Gripping of the pancreas with the endoscopic linear stapler. It is important to confirm that no surrounding tissue and/or surgical clips are involved
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the umbilical incision to 3–4 cm in length (Fig. 5a). A ring protector is then placed in this incision and the stapler is introduced into the peritoneal cavity through a surgical glove placed in this ring protector (Fig. 5a). This enlarged incision can be used for future retrieval of the specimen. The laparoscope can be inserted through both the left and right side trocars. After gripping the pancreas with the stapler, confirm that no surrounding tissue and/or surgical clips are involved (Fig. 5b). We slowly (about 10 min) transect the pancreas with the stapler. The pancreatic duct is generally closed adequately with the stapler, but small arterial arcades that are exposed in the pancreatic stump may need to be cauter-
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ized. After the pancreatic transection with the stapler, the laparoscope is again inserted through the 12-mm trocar placed in a surgical glove fixed in the ring protector.
Mobilization and extraction of the pancreatic body/tail and the spleen (Video S3) Gently grasp the pancreatic stump and lift it up and then push it toward the left/caudal side. These procedures allow good visualization of the dissection plane of the retroperitoneum/pancreatic line. Finally, the retroperitoneum lateral to the spleen and the splenorenal ligament
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Other variations Spleen preservation (Video S4)
Fig. 6 Drain placement. The tip of the peripancreatic drain is fixed to the retroperitoneal tissue close to the pancreatic stump (arrowheads) with a loose loop of an absorbable suture (arrow)
is dissected toward the superior pole of the spleen. The resected specimen is placed into a large plastic bag and extracted through the enlarged umbilical site. The spleen can be morcellated within the bag before the extraction. Drain placement After thorough flushing of the operation field with physiological saline, we perform closed drainage with small silicone drains. A drain is placed near the pancreatic stump from the left or right upper trocar site and another drain placed in the left subphrenic space from the left lower trocar site. The tip of the peripancreatic drain is fixed to the retroperitoneal tissue close to the pancreatic stump, with a loose loop of an absorbable suture (Fig. 6). This procedure prevents migration of the drain and allows easy removal of the drain when drainage is no longer required [8]. This technique may not decrease the incidence of pancreatic fistula but could eliminate the necessity for additional postoperative drainage of the pancreatic fistula.
Two surgical techniques are available to preserve the spleen [5]. Warshaw developed a technique in which splenic vessels are ligated and cut with the preservation of the short gastric and left gastroepiploic vessels (Warshaw technique) [9]. The other is a procedure originally described by Kimura et al. in which the splenic artery and vein are preserved (Kimura’s method) [10]. Spleen preservation can eliminate long-term complications related to splenectomy such as overwhelming postsplenectomy sepsis [5]. LDP is currently indicated for benign diseases and low-grade malignancies in the pancreatic body and tail; therefore, spleen preservation is preferred even for laparoscopic surgery when there is no technical problem, particularly in young patients [1]. Although the Warshaw technique during LDP reportedly requires a shorter operative time, has a lower estimated blood loss, and has a lower rate of splenic complications than total preservation of splenic vessels [1], a recent study using a large number of patients has shown that both techniques are similar in terms of the estimated blood loss, the operative time, the rates of overall morbidity, and the incidence of pancreatic fistula [5]. Furthermore, the rate of successful spleen preservation was reportedly higher in patients who underwent total preservation of splenic vessels than in patients who underwent the Warshaw technique [5]. In many recent cases, spleen-preserving LDP has been performed under complete laparoscopic surgery [10]. We perform extracorporeal spleen-preserving procedures after complete laparoscopic mobilization of the pancreatic body/ tail and spleen with splenic vessels (spleen-preserving laparoscopy-assisted distal pancreatectomy), according to the technique described by Kimura et al. [10]. Although this technique requires a 7–8 cm upper-median incision, small venous/arterial branches from/to the pancreas can be safely and meticulously divided under direct vision (Fig. 7a). Therefore, this technique could be recommended as an optional strategy in spleen-preserving LDP.
Operative outcomes Hand-assisted laparoscopic surgery Between August 2008 and July 2013, 16 patients with pancreatic tumors (benign cystic tumors, n = 9; neuroendocrine tumors, n = 5; duct cell carcinoma, n = 1; fibromatosis, n = 1) underwent LDP in our institution. The mean operating time and estimated blood loss were 269 min (range, 164–418 min) and 162 ml (range, 21–483 ml), respectively. Although one patient developed pancreatic fistula (> Grade B, the International Study Group of Pancreatic Fistula), the patients were discharged from the hospital on postoperative days 8–14.
Hand-assisted laparoscopic procedures have been used in LDP [11–13]. The use of a hand may provide some advantages while maintaining a minimally invasive approach. Although the incision for a hand port is not very small (5–8 cm), hand-assisted laparoscopic surgery enables complex retraction, palpation of major structure, control of hemorrhage by finger compression and mobilization of large cystic tumors safely [13]. Although this type of surgery is one of the options in LDP, it is valuable for
E46 Fig. 7 Spleen-preserving and hand-assisted laparoscopic distal pancreatectomy. (a) Extracorporeal spleenpreserving procedures with splenic vessels preservation during laparoscopic distal pancreatectomy after complete laparoscopic mobilization of pancreatic body/tail and the spleen. (b) Hand-assisted laparoscopic distal pancreatectomy. In this case, we adopt this procedure to handle the large (90 × 70 mm) cystic tumor gently
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47
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surgeons who are planning to introduce LDP. We now perform this type of surgery only in patients with large cystic tumors in order to handle the pancreas safely without rupturing the tumor (Fig. 7b). The wound retractor is positioned through a 7–8 cm upper-median incision. The surgeon inserts his/her doublegloved left hand into the peritoneal cavity via the wound retractor (Fig. 7b). During the procedure, the cuff of the surgeon’s outer surgical glove is turned outside-in and snapped onto the external ring of the wound retractor to prevent carbon dioxide gas leakage [14]. The upper-median small incision can accommodate an eviscerated pancreatic body/tail with or without the spleen, and it also allows extracorporeal spleen-preserving procedures described above after complete mobilization of the pancreatic body/ tail and the spleen [10]. Single-incision laparoscopic surgery The concept of laparoscopic surgery through a single incision has gained the interest of surgeons owing to its cosmetic results, with many reports of various procedures rapidly accumulating in the literature over the past 5 years. However, application of this type of surgery to LDP is highly challenging and there have been only a few case series in the literature [15–17]. Although single-incision LDP may be as effective and safe as multitrocar LDP, when performed by experts, further studies are necessary to determine the true advantage of this surgery in comparison with conventional multitrocar LDP. Conclusions Laparoscopic distal pancreatectomy appears to be technically and oncologically promising in selected patients with benign tumors and low-grade malignancies of the pancreatic body/tail, and is now widely adopted. Splenic preservation during LDP can still be technically challenging. LDP has also been carried out in patients with duct cell carcinoma of
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the pancreas, although issues about the oncological consequences of laparoscopic pancreatic surgery remain highly controversial [7]. We did not comment on the complications associated with LDP in this article; however, the main cause of morbidity in LDP continues to be the occurrence of overall pancreatic fistula, the rate of which appears to be almost identical to that in the equivalent open distal pancreatectomy [1, 3, 4]. We hope that optimal techniques to overcome such classical problems associated with distal pancreatectomy can be developed and standardized in the near future. Conflict of interest
None declared.
Author contribution Manuscript drafted: Nobutsugu Abe. Video preparation: Toshiyuki Mori. Revision: Masanori Sugiyama.
References 1. Mori T, Abe N, Sugiyama M, Atomi Y. Laparoscopic pancreatic surgery. J Hepatobiliary Pancreat Sci. 2005;12:451–5. 2. Nakamura Y, Uchida E, Nomura T, Aimoto T, Matsumoto S, Tajiri T. Laparoscopic pancreatic resection: some benefits of evolving surgical techniques. J Hepatobiliary Pancreat Sci. 2009;16:741–8. 3. Jin T, Altaf K, Xiong JJ, Huang W, Javed MA, Mai G, et al. A systematic review and meta-analysis of studies comparing laparoscopic and open distal pancreatectomy. HPB. 2012;14: 711–4. 4. Nakamura M, Nakashima H. Laparoscopic distal pancreatectomy and pancreatoduodenectomy: is it worthwhile? A meta-analysis of laparoscopic pancreatectomy. J Hepatobiliary Pancreat Sci. 2013; 20:421–8. 5. Adam J-P, Jacquin A, Laurent C, Collet D, Masson B, Fernández-Cruz L, et al. Laparoscopic spleen-preserving distal pancreatectomy: splenic vessel preservation compared with the Warshaw technique. JAMA Surg. 2013;148:246–52. 6. Abu Hilal M, Takhar AS. Laparoscopic left pancreatectomy: current concepts. Pancreatology. 2013;13:443–8. 7. Ruffolo C. Laparoscopic distal pancreatectomy: up-to-date and literature review. World J Gastroenterol. 2012;18:5329–37. 8. Sugiyama M, Suzuki Y, Abe N, Matsuoka H, Yanagida O, Masaki T, et al. Secure placement of a peripancreatic drain after a distal pancreatectomy. Am J Surg. 2010;199:178–82.
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47 9. Warshaw AL. Conservation of the spleen with distal pancreatectomy. Arch Surg. 1988;123:550–3. 10. Kimura W, Yano M, Sugawara S, Okazaki S, Sato T, Moriya T, et al. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: techniques and its significance. J Hepatobiliary Pancreat Sci. 2010;17:813–23. 11. Misawa T, Shiba H, Usuba T, Nojiri T, Kitajima K, Uwagawa T, et al. Systemic inflammatory response syndrome after handassisted laparoscopic distal pancreatectomy. Surg Endosc. 2007; 21:1446–9. 12. Laxa BU, Carbonell AM 2nd, Cobb WS, Rosen MJ, Hardacre JM, Mekeel KL, et al. Laparoscopic and hand-assisted distal pancreatectomy. Am Surg. 2008;74:481–6. 13. Iacobone M, Citton M, Nitti D. Laparoscopic distal pancreatectomy: up-to-date and literature review. World J Surg. 2012;18: 5329–37. 14. Ou CH, Yang WH. Retroperitoneoscopic hand-assisted nephroureterectomy using a homemade device. J Laparoendosc Adv Surg Tech A. 2013;23:48–51. 15. Kuroki T, Adachi T, Okamoto T, Kanematsu T. Single-incision laparoscopic distal pancreatectomy. Hepatogastroenterology. 2011;58:1022–4. 16. Misawa T, Ito R, Futagawa Y, Fujiwara Y, Kitamura H, Tsutsui N, et al. Single-incision laparoscopic distal pancreatectomy with or
E47 without splenic preservation: how we do it. Asian J Endosc Surg. 2012;5:195–9. 17. Haugvik SP, Røsok BI, Waage A, Mathisen O, Edwin B. Singleincision versus conventional laparoscopic distal pancreatectomy: a single-institution case-control study. Langenbecks Arch Surg. 2013;398:1091–6.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video S1 Laparoscopic ultrasonography and mobilization of the pancreas. Video S2 Isolation and division of the splenic vessels. Video S3 Transection of the pancreas and mobilization of the pancreatic body/tail and the spleen. Video S4 Spleen-preserving laparoscopy-assisted distal pancreatectomy.
TECHNICAL VIEW
Tips on laparoscopic distal pancreatectomy Nobutsugu Abe · Toshiyuki Mori · Masanori Sugiyama
Published online: 18 February 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract An increasing number of laparoscopic pancreatic procedures are currently carried out worldwide. Laparoscopic distal pancreatectomy (LDP) appears to be technically and oncologically promising in selected patients with benign tumors and low-grade malignancies of the pancreatic body/tail, and is now widely adopted. Here, we described our standard procedures of LDP and some tips on LDP. Recent important insights into some variations/ options of LDP including spleen preservation, hand-assisted procedure, and single-incision surgery are also reviewed in this article.
Keywords Laparoscopic distal pancreatectomy · Laparoscopic surgery
Introduction Although laparoscopic pancreatic surgery represents the most advanced application of surgical laparoscopy [1], an increasing number of laparoscopic pancreatic procedures are currently carried out worldwide [2]. Among them, laparoscopic distal pancreatectomy (LDP) is now performed more frequently in the surgical treatment of benign diseases and low-grade malignancies in the pancreatic body and tail [3, 4]. There has been no prospective randomized controlled trial comparing LDP with open distal pancreatectomy; however, recent systematic reviews have shown that LDP is a safe, feasible, and effective surgery for patients with such lesions in terms of both surgical and oncologic outcomes [3, 4]. The issue of spleen preservation in LDP has been heatedly debated and has been controversial in relation to the indications of pancreatic resections and technical problems [5–7]. Here, we focus on the technical aspects of LDP and
N. Abe (*) · T. Mori · M. Sugiyama Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan e-mail: [email protected]
describe our techniques of laparoscopic “classic” distal pancreatectomy (LDP with splenectomy). We further comment on several options/variations of LDP including spleen preservation, hand-assisted procedure, and singleincision surgery.
Operative procedures and techniques (LDP with splenectomy) Patient position and setup The patient is placed in supine position on a split-leg operating room table. The surgeon stands on the left side, the assistant on the right side, and the scope operator between the legs of the patient. Initial entry into the peritoneal cavity is made at the umbilicus by the Hasson open technique. A 12-mm trocar is introduced into the peritoneal cavity, and a pneumoperitoneum is generated using carbon dioxide at a pressure of 8–10 mmHg using a laparoscopic insufflator. A 10-mm 30-degree laparoscope is used to visualize not only the operating field but also the liver and all peritoneal surfaces through the transumbilical port. Four additional trocars (each 5–12 mm) are inserted into the left upper, left lower, right upper, and right lower quadrants under laparoscopic supervision (Fig. 1a). We use laparoscopic coagulating shears (LCS) and/or a vessel sealing system (VSS) for all the resection procedures. Retraction of the liver is sometimes necessary to ensure an adequate working space of the diaphragmatic hiatus and upper spleen, which is usually concealed under the lateral segment of the liver. Retraction of this segment is paramount for nonstressful access to this region. Such retraction can easily be achieved by simple grasping of the parietal peritoneum anterior to the hiatus with a Mini Loop Retractor II (Covidien, Mansfield, MA, USA) traversing underneath the lateral segment of the liver (Fig. 1b). To avoid compression-related injury and parenchymal fractures of the liver caused by the Mini Loop Retractor II, we place a polyurethane sponge (Securea, Hogy Medical Co., Tokyo,
E42 Fig. 1 Setup of laparoscopic distal pancreatectomy. (a) Positions of five trocars. (b) Retraction of liver. Arrowhead, Mini Loop Retractor II (Covidien, Mansfield, MA, USA); arrow, polyurethane sponge (Secrea)
Fig. 2 Wide opening of gastrocolic omentum. (a) Division of gastrocolic omentum. (b) Exposure of anterior wall of superior mesenteric vein at inferior border of pancreas. (c) Dissection of gastrosplenic ligament including short gastric vessels. Clips (arrows) should be available in case there is bleeding that needs to be controlled. (d) Dissection of phrenosplenic ligament (arrow) above superior pole of the spleen
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47
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Japan) between the liver and the Mini Loop Retractor II (Fig. 1b). Division of gastrocolic omentum The first phase of the operation is the formation of a wide opening of the gastrocolic omentum for good visualization of the anterior pancreas. Entry into the lesser sac is achieved by dividing the left side of the gastrocolic omentum. The assistant lifts up the greater curvature of the stomach using the dual grasping forceps and expands it with the forceps in both hands. This procedure gives a good field of view (Fig. 2a). Leave the gastroepiploic vessels on the stomach side of the dissection. Dissect the right side of the gastrocolic omentum from the transverse colon and anterior sheet of the transverse mesocolon. In this procedure, the end point of this dissection is confirmed upon reaching Henle’s trunk area and the superior mesenteric vein at the level of the inferior border of the pancreas. At this point, we usually
expose the anterior wall of the superior mesenteric vein at the inferior border of the pancreas (Fig. 2b). The assistant changes sides to stand on the left of the patient and pushes the gastric wall toward the right side with the right-hand grasper to put strain on the gastroepiploic arcade. Dissect the left side of the gastrocolic omentum towards the lower pole of the spleen. The resection line of the gastrocolic omentum should be confirmed from the front and back to avoid transverse colon and mesocolon injury. The dissection is then continued up to the gastrosplenic ligament including the short gastric vessels. This procedure allows complete exposure of the anterior pancreas and splenic hilum. The dissection of the gastrosplenic ligament can often be completed using the LCS or VSS; however, clips should be available in case there is bleeding that needs to be controlled (Fig. 2c). After forming this wide opening of the gastrocolic omentum, the stomach can be retracted upward to expose the anterior pancreas and the remaining attachments between the posterior stomach and the anterior
J Hepatobiliary Pancreat Sci (2014) 21:E41–E47 Fig. 3 Laparoscopic ultrasonography. (a) An ultrasonography image can be split with the video to allow for a picture-in-picture view. Arrow, laparoscopic ultrasound probe. (b) After assessment of the tumor and anatomical structures, the pancreatic transection line (arrows) is planned
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pancreas. At this point, it is preferable to dissect the phrenosplenic ligament above the superior pole of the spleen (Fig. 2d). Laparoscopic ultrasonography (Video S1) A laparoscopic ultrasound probe is inserted and applied anteriorly to the pancreas. It is useful that the ultrasonography image is split with the video to allow for a “picture-in-picture” view (Fig. 3a). Assess the tumor and plan the pancreatic transection line by laparoscopic ultrasonography (Figs 3a,b). This allows assessment of the relationship between the tumor and the splenic vessels. Laparoscopic ultrasonography plays a pivotal role in deciding whether to perform spleen preservation or not. Mobilization of the pancreas (Video S1) The next phase of the operation is mobilization of the pancreas. Divide the posterior peritoneum at the inferior border of the pancreas near the superior mesenteric vein that is exposed in the first phase of the operation (or near the planned transection line of the pancreas). Divide the retroperitoneum/pancreatic line; this plane is mostly avascular. Identify the inferior mesenteric vein as it approaches the splenic vein and avoid it. Mobilize and lift the pancreas forward from this plane to expose the splenic vein lying posterior to the pancreas (Fig. 4a). Continue to divide the peritoneum laterally toward the pancreatic tail and divide the splenocolic ligament to expose the inferior pole of the spleen (Fig. 4b). Dissection in this area must be carried out with extreme care, because hemorrhage from the splenic vessels could easily occur. It is not absolutely necessary to mobilize the spleen at this point. During this pancreatic mobilization, it is preferable to identify the splenic artery inferiorly of the pancreas (Fig. 4c).
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Next, opening the peritoneum along the superior border of the pancreas will reveal the common hepatic artery and splenic artery. The superior edge of the pancreas is carefully excluded downwards by the assistant using the lower grasping forceps, which provides a good view. Care should be taken to elevate the peritoneum with a grasping forceps prior to its incision so as to prevent injury to the small vessels. The splenic artery is then encircled with a cloth tape near its root using a right-angle forceps and completely isolated from the pancreas. If the pancreatic transection is performed above the portal vein, it is preferable that the common hepatic artery is completely separated from the pancreas. Around the planned pancreatic transection line, we usually encircle and tug the pancreas using a 5-mm-wide cloth tape to form a wide “window” below the pancreas (separation of the pancreatic neck from the superior mesenteric vein/portal vein) (Figs 4d,e). Before this procedure, dissection between the pancreas and the superior mesenteric vein/portal vein proceeding upward is necessary (Figs 4d,e). Before the pancreatic transection, assessment of the pancreatic transection line by the laparoscopic ultrasound should be done once again. The splenic vessels may be divided simultaneously during pancreatic transection using an endoscopic linear stapler. However, we prefer that pancreatic transection is carried out after dividing the splenic vessels to obtain a secure clump of these vessels. The splenic artery is first divided using clips and VSS followed by the splenic vein in the same manner at the line of the planned pancreatic transection. However, when the pancreas is transected on the right side of the SMA, it is occasionally difficult to expose the splenic vessels before transection of the pancreas. Under such situations, the splenic vessels can be divided simultaneously during pancreatic transection using the endoscopic linear stapler.
Division of the splenic vessels (Video S2)
Transection of the pancreas (Video S3)
After the pancreatic mobilization, we usually isolate the splenic vein from the posterior wall of the pancreas near the planned line of pancreatic transection.
After dividing the vessels, the pancreas is transected using an endoscopic linear stapler. To insert this stapler (over 12 mm in thickness) into the peritoneal cavity, we enlarge
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J Hepatobiliary Pancreat Sci (2014) 21:E41–E47
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(e)
(c)
Fig. 4 Mobilization of pancreas. (a) Mobilization of pancreas from avascular plane to expose splenic vein lying posterior to pancreas. (b) Division of splenocolic ligament (arrow) to expose inferior pole of spleen. (c) Identification of splenic artery located inferiorly of pancreas. *, polyurethane sponge (Secrea). (d) Dissection between the pancreas and the superior mesenteric vein/portal vein proceeds upward. SMV, superior mesenteric vein; IMV, inferior mesenteric vein. (e) Complete separation of pancreas from superior mesenteric vein/portal vein, splenic artery, and common hepatic artery. CHA, common hepatic artery; PV, portal vein; SA, splenic artery; SV, splenic vein
Fig. 5 Transection of pancreas. (a) An endoscopic linear stapler is delivered through the surgical glove fixed in a ring protector placed in an enlarged umbilical incision. (b) Gripping of the pancreas with the endoscopic linear stapler. It is important to confirm that no surrounding tissue and/or surgical clips are involved
(a)
the umbilical incision to 3–4 cm in length (Fig. 5a). A ring protector is then placed in this incision and the stapler is introduced into the peritoneal cavity through a surgical glove placed in this ring protector (Fig. 5a). This enlarged incision can be used for future retrieval of the specimen. The laparoscope can be inserted through both the left and right side trocars. After gripping the pancreas with the stapler, confirm that no surrounding tissue and/or surgical clips are involved (Fig. 5b). We slowly (about 10 min) transect the pancreas with the stapler. The pancreatic duct is generally closed adequately with the stapler, but small arterial arcades that are exposed in the pancreatic stump may need to be cauter-
(b)
ized. After the pancreatic transection with the stapler, the laparoscope is again inserted through the 12-mm trocar placed in a surgical glove fixed in the ring protector.
Mobilization and extraction of the pancreatic body/tail and the spleen (Video S3) Gently grasp the pancreatic stump and lift it up and then push it toward the left/caudal side. These procedures allow good visualization of the dissection plane of the retroperitoneum/pancreatic line. Finally, the retroperitoneum lateral to the spleen and the splenorenal ligament
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Other variations Spleen preservation (Video S4)
Fig. 6 Drain placement. The tip of the peripancreatic drain is fixed to the retroperitoneal tissue close to the pancreatic stump (arrowheads) with a loose loop of an absorbable suture (arrow)
is dissected toward the superior pole of the spleen. The resected specimen is placed into a large plastic bag and extracted through the enlarged umbilical site. The spleen can be morcellated within the bag before the extraction. Drain placement After thorough flushing of the operation field with physiological saline, we perform closed drainage with small silicone drains. A drain is placed near the pancreatic stump from the left or right upper trocar site and another drain placed in the left subphrenic space from the left lower trocar site. The tip of the peripancreatic drain is fixed to the retroperitoneal tissue close to the pancreatic stump, with a loose loop of an absorbable suture (Fig. 6). This procedure prevents migration of the drain and allows easy removal of the drain when drainage is no longer required [8]. This technique may not decrease the incidence of pancreatic fistula but could eliminate the necessity for additional postoperative drainage of the pancreatic fistula.
Two surgical techniques are available to preserve the spleen [5]. Warshaw developed a technique in which splenic vessels are ligated and cut with the preservation of the short gastric and left gastroepiploic vessels (Warshaw technique) [9]. The other is a procedure originally described by Kimura et al. in which the splenic artery and vein are preserved (Kimura’s method) [10]. Spleen preservation can eliminate long-term complications related to splenectomy such as overwhelming postsplenectomy sepsis [5]. LDP is currently indicated for benign diseases and low-grade malignancies in the pancreatic body and tail; therefore, spleen preservation is preferred even for laparoscopic surgery when there is no technical problem, particularly in young patients [1]. Although the Warshaw technique during LDP reportedly requires a shorter operative time, has a lower estimated blood loss, and has a lower rate of splenic complications than total preservation of splenic vessels [1], a recent study using a large number of patients has shown that both techniques are similar in terms of the estimated blood loss, the operative time, the rates of overall morbidity, and the incidence of pancreatic fistula [5]. Furthermore, the rate of successful spleen preservation was reportedly higher in patients who underwent total preservation of splenic vessels than in patients who underwent the Warshaw technique [5]. In many recent cases, spleen-preserving LDP has been performed under complete laparoscopic surgery [10]. We perform extracorporeal spleen-preserving procedures after complete laparoscopic mobilization of the pancreatic body/ tail and spleen with splenic vessels (spleen-preserving laparoscopy-assisted distal pancreatectomy), according to the technique described by Kimura et al. [10]. Although this technique requires a 7–8 cm upper-median incision, small venous/arterial branches from/to the pancreas can be safely and meticulously divided under direct vision (Fig. 7a). Therefore, this technique could be recommended as an optional strategy in spleen-preserving LDP.
Operative outcomes Hand-assisted laparoscopic surgery Between August 2008 and July 2013, 16 patients with pancreatic tumors (benign cystic tumors, n = 9; neuroendocrine tumors, n = 5; duct cell carcinoma, n = 1; fibromatosis, n = 1) underwent LDP in our institution. The mean operating time and estimated blood loss were 269 min (range, 164–418 min) and 162 ml (range, 21–483 ml), respectively. Although one patient developed pancreatic fistula (> Grade B, the International Study Group of Pancreatic Fistula), the patients were discharged from the hospital on postoperative days 8–14.
Hand-assisted laparoscopic procedures have been used in LDP [11–13]. The use of a hand may provide some advantages while maintaining a minimally invasive approach. Although the incision for a hand port is not very small (5–8 cm), hand-assisted laparoscopic surgery enables complex retraction, palpation of major structure, control of hemorrhage by finger compression and mobilization of large cystic tumors safely [13]. Although this type of surgery is one of the options in LDP, it is valuable for
E46 Fig. 7 Spleen-preserving and hand-assisted laparoscopic distal pancreatectomy. (a) Extracorporeal spleenpreserving procedures with splenic vessels preservation during laparoscopic distal pancreatectomy after complete laparoscopic mobilization of pancreatic body/tail and the spleen. (b) Hand-assisted laparoscopic distal pancreatectomy. In this case, we adopt this procedure to handle the large (90 × 70 mm) cystic tumor gently
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(a)
surgeons who are planning to introduce LDP. We now perform this type of surgery only in patients with large cystic tumors in order to handle the pancreas safely without rupturing the tumor (Fig. 7b). The wound retractor is positioned through a 7–8 cm upper-median incision. The surgeon inserts his/her doublegloved left hand into the peritoneal cavity via the wound retractor (Fig. 7b). During the procedure, the cuff of the surgeon’s outer surgical glove is turned outside-in and snapped onto the external ring of the wound retractor to prevent carbon dioxide gas leakage [14]. The upper-median small incision can accommodate an eviscerated pancreatic body/tail with or without the spleen, and it also allows extracorporeal spleen-preserving procedures described above after complete mobilization of the pancreatic body/ tail and the spleen [10]. Single-incision laparoscopic surgery The concept of laparoscopic surgery through a single incision has gained the interest of surgeons owing to its cosmetic results, with many reports of various procedures rapidly accumulating in the literature over the past 5 years. However, application of this type of surgery to LDP is highly challenging and there have been only a few case series in the literature [15–17]. Although single-incision LDP may be as effective and safe as multitrocar LDP, when performed by experts, further studies are necessary to determine the true advantage of this surgery in comparison with conventional multitrocar LDP. Conclusions Laparoscopic distal pancreatectomy appears to be technically and oncologically promising in selected patients with benign tumors and low-grade malignancies of the pancreatic body/tail, and is now widely adopted. Splenic preservation during LDP can still be technically challenging. LDP has also been carried out in patients with duct cell carcinoma of
(b)
the pancreas, although issues about the oncological consequences of laparoscopic pancreatic surgery remain highly controversial [7]. We did not comment on the complications associated with LDP in this article; however, the main cause of morbidity in LDP continues to be the occurrence of overall pancreatic fistula, the rate of which appears to be almost identical to that in the equivalent open distal pancreatectomy [1, 3, 4]. We hope that optimal techniques to overcome such classical problems associated with distal pancreatectomy can be developed and standardized in the near future. Conflict of interest
None declared.
Author contribution Manuscript drafted: Nobutsugu Abe. Video preparation: Toshiyuki Mori. Revision: Masanori Sugiyama.
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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video S1 Laparoscopic ultrasonography and mobilization of the pancreas. Video S2 Isolation and division of the splenic vessels. Video S3 Transection of the pancreas and mobilization of the pancreatic body/tail and the spleen. Video S4 Spleen-preserving laparoscopy-assisted distal pancreatectomy.
